Introduction: Tumours of the pituitary gland and sellar region represent 10-15% of all brain tumours. Pituitary  macroadenoma is the most common suprasellar mass in adults and is the commonest indication for transnasal  trans-sphenoidal hypophysectomy. Case Report: A 41-year-old patient presented with right-sided loss of vision and right-sided headache for 3  months and posted for the Transnasal Trans-sphenoidalhypophysectomy. The patient previously underwent a  similar surgery for an invasive non-functioning pituitary adenoma 2.5 years back. He is a known hypothyroid, with  normal vitals and class III Mallampati. The possibility of a difficult airway was considered because of the enlarged  tongue. Other system examinations were normal. The hemogram and biochemistry measurements were normal.  MRI brain showed a mass lesion measuring 5.2 x 5.6 x 4.7 cm in the sellar, supra, and parasellar regions. We were  prepared for all the intraoperative complications of pituitary macroadenoma that can happen. Difficult airway cart was made available. 18-gauge IV cannula secured. Pre-oxygenated and premedicated with  IV Glycopyrrolate 0.01mg/Kg and IV Fentanyl 2 mcg/Kg. Induced with Propofol 2mg/Kg, checked ventilation  and Vecuronium 0.1mg/Kg was administered. Intubated with 8.5 mm cuffed endotracheal tube using Video  laryngoscope. Right Subclavian vein cannulated and Invasive BP monitored through Radial artery cannulation.  Anesthesia was maintained with Oxygen-Nitrous oxide, Isoflurane, Vecuronium, and Dexmedetomidine infusion.  The patient was hemodynamically stable throughout the procedure. At the end of the procedure, reversal was  given and extubated after ensuring adequate recovery. Conclusion: Appropriate assessment before anesthesia and perioperative adequate monitoring and preparation  are important in the management of anesthesia of patients with pituitary macroadenoma. Keywords: Anesthetic concerns in pituitary adenoma, Neurosurgical Anesthesia, Pituitary Tumours, Pituitary  Macroadenomas. Key Messages: Patients coming for recurrent pituitary macroadenoma need appropriate preoperative  assessment and perioperative anesthesia management. This surgery requires a multidisciplinary team that includes  an anesthesiologist, an endocrinologist, a neurosurgeon and a radiologist for better patient care and outcome. We  are presenting a case report of recurrent pituitary macroadenoma and its successful management.